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Rev. 03/09/2017

Authorization to Release Medical Records Patient records are available on Epic’s Care Everywhere Network via Legacy and also by fax, secure email, or mail.

Patient Name: ______________________________________________ Date of Birth: ______/_______/_______ Phone: (_______) __________________

Address: _____________________________________________________________________________________________________________________ Street City State Zip Code

I Authorize My Health Information to Be: Sent to: Verbally exchanged with:

Requested from: I don’t need records at this time.

Name: _________________________________________________________________

Address: _______________________________________________________________

City/State/Zip: __________________________________________________________

Phone: (_______)_____________________ Fax: (_______) __________________________

Email: __________________________________________________________________

My health information: MAY or MAY NOT be faxed.

MAY or MAY NOT be securely emailed.

Purpose of Release: Changing Physician/Clinic*

Personal Use**

Legal

Other: _________________________

*Records sent to outside physicians/clinics are

provided free of charge.

**There is a flat copy charge of $20.00 for any

personal request for medical records. Please

make checks payable to: Metropolitan Pediatrics.

Your request will be processed within 30 days.

Indicate Type of Information to Be Released Below: General Medical Records

excluding protected records.

Copies of medical records will be

limited to two (2) years of

information including progress

notes, lab and x-ray reports, and

immunizations.

–OR– Specific Information Only: All Medical Records Specify Date(s): _____________________

Medications

Lab, Pathology, EKG Specify Type/Date: __________________ X-ray Reports

Immunizations Only

Other Please Specify: _____________________

Protected or Sensitive Information: I understand that certain information cannot be

released without specific authorization as required

by State/Federal law. By INITIALING, I authorize the

release of the following protected or sensitive

information. Patients 14+ must provide initial.

______ (initial) DRUG & ALCOHOL DIAGNOSIS/TREATMENT

______ (initial) ADD/MENTAL HEALTH TREATMENT

______ (initial) AIDS/HIV TEST RESULTS including related high risk behavior

______ (initial) GENETIC TESTING

I understand that information used or disclosed pursuant to this authorization may be subject to re-disclosure and no longer protected under federal law.

However, I also understand that federal or state law may restrict re-disclosure of HIV/AIDS, mental health information, genetic testing information, and

drug/alcohol diagnosis, treatment, or referral information.

You are under no obligation to sign this form, and you may refuse to do so. Treatment, payment, enrollment, or eligibility benefits may not be conditioned on

signing this authorization, with the exception of obtaining information in connection with eligibility or enrollment in a health plan.

You have the right to revoke this authorization at any time by providing a written request for revocation to Metropolitan Pediatrics’ Health Information Services

Department. If you revoke the authorization, the revocation will not affect any disclosures that were made prior to processing the revocation request. Unless

otherwise revoked, this authorization will expire 1 year from the date signed or will expire on the following date, event, or condition: _________________________.

X________________________________________ _______________________________________ X_____/_____/_____ Signature of Parent or Legally Responsible Person Print Name | Relationship Date

X________________________________________ _______________________________________ X_____/_____/_____ Signature of Patient 14+ years – REQUIRED Print Name Date

INTERNAL USE ONLY I have verified: Form is complete Identity of requester

Relationship (if not patient) Payment received: _____/_____/_____

Employee Name: Date: _____/_____/_____

Send Records / Record Requests / Revocation Requests to Metropolitan Pediatrics – Health Information Services Department: 15455 NW Greenbrier Parkway, Suite 112 Beaverton, OR 97006 503-601-3417 F 503-466-1858 HIS@metropediatrics.com

Rev. 08/19/2019

Patient Information Form Parent Information

Name: _______________________________________________ Last First MI

SSN: _______________________ DOB: / / M F

Relationship to Patient: ________________________________

Marital Status: Married Single Divorced Widowed

Address: _____________________________________________

City/State/Zip: ________________________________________

Email: _______________________________________________

Home: (_____)____________ Cell: (_____) __________________

How did you hear about us? ___________________________

Other Parent Information

Name: _______________________________________________ Last First MI

SSN: _______________________ DOB: / / M F

Relationship to Patient: ________________________________

Marital Status: Married Single Divorced Widowed

Address: _____________________________________________

City/State/Zip: ________________________________________

Email: _______________________________________________

Home: (_____)____________ Cell: (_____) __________________

Patient Information New Patient? Y N

Name: ______________________________________________ Last First MI

SSN: _______________________ DOB: / / M F

Other Children in Family Patient Here? Y N

Name: ______________________________________________ Last First MI

SSN: _______________________ DOB: / / M F

Patient Here? Y N

Name: ______________________________________________ Last First MI

SSN: _______________________ DOB: / / M F

Patient Here? Y N

Name: ______________________________________________ Last First MI

SSN: _______________________ DOB: / / M F

Emergency Contact

Name: ______________________________________________ Last First MI

Relationship to Patient: _______________________________

Home: (_____)____________ Cell: (_____) _________________

Billing Information Private Pay (No Insurance)

Insurance (Primary) Eff. Date: / /___

Insurance Co: ________________________________________

Employer: ___________________________________________

Policyholder: ________________________ DOB: / /___

Policy#: _____________________________________________

Group#: ____________________ Copay: $ _________________

OHP: CareOregon Providence Health Assurance

Open Card

Insurance (Secondary) Eff. Date: / /___

Insurance Co: _______________________________________

Employer: ___________________________________________

Policyholder: ________________________ DOB: / /___

Policy#: _____________________________________________

Group#: ____________________ Copay: $ ________________

Consent for Treatment: I authorize the physicians and clinic personnel of Metropolitan Pediatrics, LLC, to conduct physical examinations and routine services, order and perform tests,

and administer treatment deemed necessary by the examining physician. Should treatment be performed, the physician will fully inform me as to the nature of the procedure, the

alternatives to treatment, and the risks involved. I will be given the opportunity to ask questions and have my questions answered. Should special procedures be indicated, I understand

that the examining physician will discuss this with me and that additional consent(s) may be required.

Financial Responsibility: I understand that I am responsible for all charges resulting from treatment provided by Metropolitan Pediatrics, LLC, as well as any agency and/or legal fees

incurred should my account be placed in a collection status. I agree to pay the balance due within 30 days of statement billing unless I have made other payment arrangements.

Assignment of Benefits: I authorize my insurance carrier(s) to remit payment of benefits for any claim to Metropolitan Pediatrics, LLC. I understand that any ineligible or non-covered

expenses are my responsibility. I assign Metropolitan Pediatrics, LLC, as an Authorized Representative to: (1) Submit any and all appeals when my insurance company denies me

benefits to which I am entitled, (2) Submit any and all requests for benefit information from my insurance company, (3) Initiate formal complaints to any state or federal agency that has

jurisdiction over my benefits, and (4) Release all medical information necessary to process my claims. I authorize any plan administrator or insurer to release any and all plan

documents, insurance policy, and/or settlement information upon written request from Metropolitan Pediatrics, LLC. This assignment is valid for all administrative and judicial reviews

under PPACA, ERISA, Medicare, and applicable federal or state laws. A photocopy of this assignment is to be considered as val id as the original.

X__________________________________________ _______________________ ___________ X_____/_____/_____ Signature of Patient, Parent, or Legally Responsible Person Print Name Relationship Date

Rev. 07/20/2016 MORE QUESTIONS ON THE BACK SIDE

Patient Intake Form Patient Name: ___________________________________________________________________ Date of Birth: ______/_______/_______

MR#: _________________________________________________________________________ Date of Service: ______/_______/_______

American Indian or Alaska Native

Native Hawaiian or Other Pacific Islander

Asian

White (non-Hispanic)

Black or African American

Other

Hispanic

Welcome to Metropolitan Pediatrics! Please take the time to fill out this form as accurately as possible so we can

most appropriately address your child’s health needs. Thank you!

Birth History – Pregnancy: Did mother: Smoke? Yes No

Drink alcohol? Yes No

Use drugs/medications? Yes No

If yes, what kind(s)? ___________________________

_____________________________________________

Experience illness/complications? Yes No

If yes, what kind(s)? ___________________________

_____________________________________________

Birth History – Delivery/Newborn Period: Delivery Type: Vaginal C-section

Gestational Age: ___________ Birth Weight: ___________

Date hepatitis B given: ______/_______/_______

Problems in newborn period: _______________________

__________________________________________________

__________________________________________________

__________________________________________________

__________________________________________________

__________________________________________________

Patient Medical History: ADD/ADHD

Allergies

Anxiety

Arthritis

Asthma

Cancer/Oncology

Diabetes mellitus

Eating disorder

Eczema

Headaches

Hearing loss

Heart murmur

Immune deficiency

Inflammatory bowel disease

Jaundice

Meningitis

Otitis media

Pneumonia

Prematurity

Scoliosis

Seizures

Sickle cell

Strep throat (recurrent)

Thyroid disease

Tuberculosis

UTI

Varicella (chickenpox)

Vision problems

Other: __________________________________________________________________________________________________________

________________________________________________________________________________________________________________

________________________________________________________________________________________________________________

Patient Surgical History: Adenoidectomy

Appendectomy

Circumcision

Cleft lip

Cleft palate

Cosmetic Surgery

C-section

Fracture surgery

Heart surgery

Hernia repair

Inguinal hernia

Lymph node biopsy

Tonsillectomy

Ear tubes

Umbilical hernia

Undescended testicle surgery

Other: __________________________________________________________________________________________________________

________________________________________________________________________________________________________________

________________________________________________________________________________________________________________

Rev. 07/20/2016

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__________________________________________________________________________________________________________________________________

__________________________________________________________________________________________________________________________________

__________________________________________________________________________________________________________________________________

__________________________________________________________________________________________________________________________________

Thyroid Disease

Sudden Death

Substance Abuse

Seizures

Rheumatologic Disease

Obesity

Kidney Disease

High Cholesterol

High Blood Pressure

Heart Disease

Heart Defect

Hearing Loss

Eczema

Early Death

Diabetes

Developmental Delay

Depression

Clotting Disorder

Bleeding Problem

Birth Defects

Asthma

Arthritis

Allergy-Severe

ADHD

Other

No Known Problems

Lives with patient?

Date

of B

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Rev. 07/18/2016

Genetic Privacy Notice Notice of Your Right to Decline Participation in Future Anonymous or Coded Genetic Research

Metropolitan Pediatrics, LLC, is required by Oregon law to provide this notice to you regarding the use of your health information

or biological samples for genetic research (OAR 333-025-0100-333-025-0165). State law protects the genetic privacy of

individuals and gives you the right to decline to have your health information or biological samples used for research.

A biological sample may include a blood sample, urine sample, or other materials collected from your body. You can decide

whether to allow your health information or biological samples to be available for genetic research. Your decision will not affect

either the care you receive from your health care provider or your health insurance coverage.

Research is important because it gives us valuable information on how to improve health, such as ways to prevent or better treat

heart disease, diabetes, and cancer. Under Oregon law, a special team reviews all genetic research before it begins. The team

makes sure that the benefits of the research are greater than any risks to participants.

In anonymous research, personal information that could be used to identify you, such as your name, Social Security number, or

medical record number cannot be linked to your health information or biological sample. In coded research, personal information

that could be used to identify you is kept separate from your health information or biological sample, making it very difficult to

link your personal information to your health information or biological sample. Your identity is protected in both types of

research.

If you DO NOT want to have your health information and biological sample available for anonymous or coded genetic research,

YOU MUST tell your health care provider by checking the box below, signing, and returning the form as directed by your clinic

representative.

Genetic Privacy Opt Out Statement: I have read and understand the above Genetic Privacy Notice, and I DO NOT want to have my health

information and biological samples available for anonymous or coded genetic research.

If you want to allow your health information and biological sample to be available for anonymous or coded genetic research,

please sign and return this form without checking the opt out box. If you make this choice, your health information or biological

sample may be used for anonymous or coded genetic research without further notice to you.

No matter what you decide now, you can always change your mind later by completing this form and returning it to your health

care provider. Your new decision is effective on the date your health care provider receives the Genetic Privacy Opt Out, and will

apply only to health information or biological samples collected after your health care provider receives the form. If you have

questions about Genetic Testing, please call the Oregon Genetics Program at 971-673-0271.

This form will be retained in your medical chart throughout your relationship with Metropolitan Pediatrics, LLC.

Patient Name (PRINT): _______________________________________________________ Patient DOB: _____/_____/_____

X__________________________________________ _______________________ X_____/_____/_____ Signature of Patient or Legally Responsible Person Relationship to Patient Date